Seasons Hospice Employment Application

Minnesota License/Certificate Type

Minnesota License/Certificate Number

State (U.S. Only)

Country

Expiration Date

Date

Date available to start*

Date

Number of hours per week*

Full time (30-40 hours per week)Part time (less than 30 hours per week)As needed (no regularly scheduled hours)

Shift Availability*

DayEveningNightWeekends

Please specify any days or hours NOT available to work

Name of Employer*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Position *

Employment start date*

Date

Currently employed

Employment end date*

Date

Reason for leaving*

Name of Employer

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Position *

Employment start date*

Date

Currently employed

Employment end date*

Date

Reason for leaving*

Name of Employer

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Position *

Employment start date*

Date

Currently employed

Employment end date*

Date

Reason for leaving*

Are there gaps in your work history? If yes, explain:

Are there gaps in your work history? If yes, please explain:

Institution name

Years attended

Major

Did you graduate? If no, explain:

Please list any other information about your professional background that you feel would be beneficial to the position you are applying for:

Applicant Statement
Please read the following information carefully. By signing below, you are agreeing to the following:

1. I understand that the receipt of this application does not imply I will be employed nor does it indicate that there are positions available.
2. I understand that unless acted upon, this application will become inactive after 180 days. After that time, I will have to reapply to receive further consideration.
3. I hereby grant permission to investigate any of the information included in this application, agree to cooperate in such investigation and release from all liability or responsibility all persons, organizations, companies and corporations collecting and supplying such information together with any other information they may have regarding me whether or not it is in their records.
4. In making this application for employment, I understand that an investigation may be made whereby information is obtained through interviews with my references, including but not limited to former co-workers, supervisors, business associates, etc. or others with whom I am acquainted. This inquiry includes information as to my criminal record, reputation, professional credentials, and work ethics. I understand that I have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.
5. I understand that if I am hired, my employment will be at-will and may be terminated with or without cause and with or without notice at any time. I also understand that no employee of Seasons Hospice other than the Executive Director has authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing.
6. I understand that if I am employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.
7. I certify the information included in this application is true and correct, and without consequential omissions of any kind.

Digital Signature*

Please type your first and last name. By signing, you are agreeing to the above applicant statement.

Date signed*

Position Information

Professional Licenses & Certifications

Availability

Employment History

Employer #1

Employer #2

Employer #3

Education & Training